Radiological Findings in Hepatobiliary Fascioliasis

Transcription

1 ORİJİNAL ARAŞTIRMA Radiological Findings in Hepatobiliary Fascioliasis Serhat AVCU, MD, a Aydın BORA, MD, a Halil ARSLAN, MD, a Mustafa K. KARAHOCAGİL, MD, b Mahmut SÜNNETÇİOĞLU, MD b Departments of a Radiology and b Infectious Diseases, Yüzüncü Yıl University Faculty of Medicine, Van Ge liş Ta ri hi/re ce i ved: Ka bul Ta ri hi/ac cep ted: Ya zış ma Ad re si/cor res pon den ce: Serhat AVCU, MD Yüzüncü Yıl University Faculty of Medicine, Department of Radiology, Van, TÜRKİYE/TURKEY serhatavcu@hotmail.com ABS TRACT Ob jec ti ve: In this study, ra di o lo gi cal fin dings of 24 re la ti ves we re eva lu a ted who we - re di ag no sed with he pa to bi li ary fas ci o li a sis with se ro lo gic tes ting and exa mi na ti on of fa mily members. Ma te ri al and Met hods: Twenty-fo ur pa ti ents we re eva lu a ted by ab do mi nal ul tra so nog raphy (US), 23 pa ti ents by com pu ted to mog raphy (CT) and 4 pa ti ents by mag ne tic re so nan ce cho lan gi o - pan cre a tog raphy (MRCP). Li ver func ti on tests, ro u ti ne bi oc he mistry, IgE and eo si nop hil le vels we - re analy sed in all pa ti ents. Re sults: Ab do mi nal US de tec ted pat ho logy in 13 pa ti ents and no pat ho logy in 11. CT was per for med in 23 pa ti ents, and he pa to bi li ary le si ons we re de tec ted in 20. Of the 6 ca ses with bi li ary di la ta ti on, 4 pe rip he ral en han ce ments of the bi le ducts we re no ti ced on CT exa mi na ti on. Mild bi li ary di la ta ti on was ob ser ved in all of the 4 pa ti ents who we re eva lu a ted with MRCP and fil ling de fects in the bi le ducts we re fo und in 2 of them. ELISA test for Fasciola hepatica was positive in all 24 patients. IgE level was elevated in 19 patients, and eosinophil level was elevated in 17 patients, Leucocyte level was elevated in 14 patients, and alcatene phosphatase level was elevated in 10 patients. Conc lu si on: In acu te pha se, CT is and high IgE and eo si nop hil le vels with typi cal CT fin dings are sig ni fi cant in the di ag no sis. The pe rip he ral en han ce ment of ex tra he - pa tic bi le ducts may be a clu e for bi li ary in vol ve ment of the di se a se. MRCP is a use ful met hod in de mons tra ting bi li ary di la ta ti on and in tra lu mi nal fil ling de fects, which cor res pond to pa ra si tes. Key Words: Fas ci o la he pa ti ca, fas ci o li a sis, bi li ary, com pu ted to mog raphy ÖZET Amaç: Bu ça lış ma da, bir bi riy le ak ra ba lı ğı bu lu nan, ai le araş tır ma sı ve se ro lo jik test ler so nu - cun da he pa to bi li yer fa si o li ya zis ta nı sı alan 24 has ta nın rad yo lo jik bul gu la rı de ğer len di ril miş tir. Ge - reç ve Yön tem ler: Yir mi dört has ta ab do mi nal ul tra so nog ra fi (US), 23 has ta bil gi sa yar lı to mog ra fi (BT) ve 4 has ta man ye tik re zo nans ko lan ji yo pan kre a tog ra fi (MRKP) ile de ğer len di ril di. Bü tün has - ta lar da ka ra ci ğer fonk si yon test le ri, ru tin bi yo kim ya, IgE ve eo zi no fil dü zey le ri ana liz edil di. Bul - gu lar: Ab do mi nal US ile 11 has ta da bul gu el de edil mez ken, 13 has ta da pa to lo ji sap tan dı. Yir mi üç has ta da ab do mi nal BT in ce le me si ya pıl dı ve bun la rın 20 sin de he pa to bi li yer lez yon lar tes pit edil - di. BT'de saf ra yol la rın da di la tas yon sap ta nan 6 has ta nın 4 ün de saf ra yol la rın da çev re sel kon trast - lan ma dik ka ti çek ti. MRKP in ce le me si ger çek leş ti ri len 4 has ta nın hep sin de saf ra yol la rın da ha fif ge niş le me ve 2 sin de saf ra yol la rın da do lum de fekt le ri sap tan dı. Fas ci o la he pa ti ca için ya pı lan ELI - SA tes ti 24 has ta nın ta ma mın da po zi tif ti. IgE 19 has ta da, eo zi no fil dü ze yi 17 has ta da yük sek bu lun - du. Lö ko sit se vi ye si 14 has ta da, al ka len fos fa taz se vi ye si 10 has ta da nor mal den yük sek bu lun du. So nuç: He pa to bi li yer fa si o li ya zi sin akut ev re sin de BT US'den da ha et ki li bir teş his yön te mi dir ve ti pik BT bul gu la rı ile bir lik te yük sek IgE ve eo zi no fil dü zey le ri ta nı da önem arz et mek te dir. Eks - tra he pa tik saf ra yol la rı nın çev re sel kon trast lan ma sı has ta lı ğın bi li yer tu tu lu mu açı sın dan bir ipu - cu ola bi lir. MRKP saf ra yol la rın da ki ge niş le me yi gös ter me de ve pa ra zit le re kar şı lık ge len lü men içi do lum de fekt le ri ni sap ta ma da önem li bir gö rün tü le me yön te mi dir. Anah tar Ke li me ler: Fa si o li ya zis; bi li yer; Fas ci o la he pa ti ca; bil gi sa yar lı to mog ra fi Turkiye Klinikleri J Med Sci 2009;29(5): Cop yright 2009 by Tür ki ye Kli nik le ri ascioliasis is a hepatobiliary system disease caused by the liver fluke Fasciola hepatica. It infects human beings by contaminated water and green vegetables, especially watercress. The disease consists of Turkiye Klinikleri J Med Sci 2009;29(5) 1149

2 Avcu ve ark. he pa tic and bi li ary pha ses. Se ro logy is used as a ba - sic di ag nos tic mo da lity. Ra di o lo gi cal fin dings of the di se a se ha ve be en re por ted in the last de ca de. Alt ho ugh the di se a se has so me ra di o lo gi cally sig ni fi cant fin dings, it may ma ni fest with dif fe rent pat terns. CT is a very ef fi - ci ent di ag nos tic mo da lity in he pa tic pha se of the di se a se and helps with the di ag no sis in 90% of the pa ti ents with acu te fas ci o li a sis. It shows mul tip le, small, hypo dens le si ons with ir re gu lar bor ders, as well as branc hing fo ci of mic ro abs ces ses and subcap su lar lo ca li za ti on of the le si ons, which are the cha rac te ris tic CT fin dings of the di se a se. In contrast, US is mo re ef fec ti ve than CT in bi li ary pha se of the di se a se. Mi xed pa rench ymal ec ho ge ni ti es with ir re gu lar bor ders, cur vi li ne ar, oval, le af-li ke or cong lo me ra te hype rec ho ge ni ti es wit ho ut aco us tic sha do wing in the gall blad der, or mo ving pa ra si tes wit hin the di la ted lu men may be se en with US. 1-4 Most of the stu di es on fas ci o li a sis in vol ved spo ra dic ca ses that we re di ag no sed af ter pre sen ta - ti on to the hos pi tal with va ri o us symptoms. In this study, ra di o lo gi cal fin dings in he pa to bi li ary fas ci o - la sis of 24 re la ti ves we re eva lu a ted who we re di ag - no sed af ter fa mily in ves ti ga ti on. MA TE RI AL AND MET HODS Af ter the ra di o lo gi cal and se ro lo gi cal di ag no sis of he pa to bi li ary fas ci o li a sis in two pa ti ents whit a history of ea ting wa ter cress re cently, fa mily in ves ti - ga ti on was per for med in 79 re la ti ves who had a si mi lar his tory. Of the 79 re la ti ves, 24 ca ses we re inc lu ded in this study, which we re ve ri fi ed as fasci o li a sis se ro lo gi cally using the ELI SA test. Thre e of the pa ti ents we re ma le and the re ma i ning ca ses we re fe ma le. The me an age of the pa ti ents was 23 (ran ge 5-64). All pa ti ents we re eva lu a ted by ab do mi nal US (Phi lips HD 11, Bot hell, Was hing ton, USA), 23 pati ents by con trast en han ced ab do mi nal CT (Si e - mens Sen sa ti on 4, Er lan gen, Ger many), and 4 ca ses by MRCP (Si e mens Symphony, Er lan gen, Germany). One of the pa ti ents was preg nant and co - uld not be eva lu a ted by CT. Li ver func ti on tests, ro u ti ne bi oc he mistry, IgE and eo si nop hil le vels we - re analy sed in all pa ti ents. All the ra di o lo gi cal fin - dings we re do cu men ted and we re com pa red with cli ni cal and la bo ra tory fin dings. In for med con sent was ob ta i ned from all pa ti ents. RE SULTS Radyoloji All ca ses we re de tec ted for fa mily in ves ti ga ti on and no ne of them had any se ri o us symptoms. Most of them had non-spe ci fic symptoms such as ab do mi - nal dis com fort, na u se a, lack of ap pe ti te, we ak ness, fa ti gu e, and he a dac he for the last few months. La bo ra tory da ta of the 24 ca ses re ve a led that IgE was high in 19, and eo si nop hi li a was de tec ted in 17. Pa ra si tes we re de tec ted in sto ol only in 11 ca ses. All the la bo ra tory fin dings we re sum ma ri zed in Tab le 1. Ab do mi nal US was ava i lab le in all pa ti ents and de tec ted pat ho logy in 13 pa ti ents and did not in 11. He pa to me galy, mi ni mal pa rench ymal ir re gu la rity, ge og rap hic hypo ec ho ic fo ci of le si ons that co uld not be dif fe ren ti a ted ea sily from the nor mal li ver pa rench yma mostly lo ca ted at pe rip he ral and subcap su lar are as we re the ma in so nog rap hic fin dings (Fi gu re 1). Ab do mi nal CT was per for med in 23 pa ti ents and he pa to bi li ary le si ons we re de tec ted in 20. The - re was no any pat ho logy in 3 ca ses. The most evi - dent fin ding on CT was low at te nu a ted no du lar mas ses with ir re gu lar mar gins of dif fe rent si zes TABLE 1: Laboratory findings according to number of patients. Laboratory findings Number of patients ELISA (+) 24 Leucocyte (WBC) 14 GGT 5 LDH 8 ALP 10 IgE 19 Eosinophile 17 ALT 7 AST 6 Parasite in stool 11 ELI SA: Enz yme-lin ked im mu no sor bent as say, WBC: Whi te blo od cell, GGT: Gam ma glu tamyl trans fe ra se, LDH: Lac ta te dehy dro ge na se, ALP: Al ca le ne phosp ha ti se, IgE: im mu nog lo bu li ne E, ALT: Ala ni ne ami not rans fe ra se, AST: As par ta te ami not rans - fe ra se Turkiye Klinikleri J Med Sci 2009;29(5)

3 Radiology Avcu et al Of the 6 ca ses with bi li ary di la ta ti on, 4 pe rip - he ral en han ce ments of the ma in bi le ducts we re no ti ced on CT exa mi na ti on (Fi gu re 4a, b). Mild bi l- i ary di la ta ti on was ob ser ved in all of the 4 pa ti ents who we re eva lu a ted with MRCP and fil ling de fects in the bi le ducts we re fo und in 2 of them (Fi gu re 5a, b). Tric la ben da zo le tre at ment was gi ven to all pati ents. All pa ti ents are still un der cli ni cal fol lowup and we plan to re pe at ra di o lo gi cal exa mi na ti ons. DIS CUS SI ON FIGURE 1: Geographic hyperechoic foci (arrows) of lesions that could not be differentiated easily from the normal liver parenchyma, and nonhomogenous liver parenchyma. Alt ho ugh fas ci o li a sis in fec ti on has be en well do cu - men ted in all as pects, di ag no sis and tre at ment co uld be de la yed be ca u se it is usu ally not con si de red in the dif fe ren ti al di ag no sis. Anot her re a son of la te diag no sis or mis di ag no sis is that the ra di o lo gi cal cha r- ac te ris tics of the di se a se we re de li ne a ted in the last and are still unc le ar in so me as pects. Ra di o lo gi cal fin dings de pend on the pha se of the di se a se, the he- FIGURE 2: Focal hypodens lesions especially in the right lobe that tend to fuse peripherally in the subcapsular localization. sho wing cong lo me ra ti on li kely to be abs cess forma ti on lo ca ted pe rip he rally and sub cap su larly espe ci ally in the right lo be (Fi gu re 2). The re we re al so tract li ne fas hi on le si ons in the pa rench yma among the hypo dens no du lar are as. The le si ons did not show pro mi nent con trast up ta ke or a litt le perip he ral en han ce ment was de tec ted in so me of them af ter ad mi nis tra ti on of in tra ve no us con trast me di um (Fi gu re 3). Ot her fin dings we re he pa to - me galy, bi li ary pat ho logy, pe ri por tal lymph no des and sple no me galy. All the CT fin dings we re summa ri zed in Tab le 2. FI GU RE 3: Hypo dens le si ons li ke moth-bit ten ap pe a ran ce that do not enhan ce af ter con trast me di a in jec ti on and re mind mic ro abs cess for ma ti ons that tend to be conf lu ent. TABLE 2: CT findings according to number of patients. CT findings Number of patients Multifocal hypodens lesions in the liver 16 Tract line fashion lesion 13 Hepatomegaly 11 Hilar lymphadenopathy 7 Intrahepatic biliary dilatation 6 Peripheral enhancement of the common bile duct 4 Splenomegaly 2 Turkiye Klinikleri J Med Sci 2009;29(5) 1151

4 Avcu ve ark. Radyoloji a FIGURE 4a,b: Peripheral enhancement (arrows) of the bile ducts (a,b). b a FIGURE 5a,b: (a) Mild biliary dilatation and (b) filling defects (arrow) in the bile ducts (b) on MRCP. b pa tic and bi li ary pha ses, which show dif fe rent symptoms and ra di o lo gi cal fin dings. Af ter in ges ti on of the con ta mi na ted ma te ri al with fas ci o la he pa ti ca, the me ta ser ca ri as pe net ra te in to the in tes ti nal wall, pe ri to ne al ca vity and the li ver cap su le, and lod ge wit hin the bi li ary system pas sing thro ugh the li ver pa rench yma. This pe ri od ta kes ne arly 3-4 months and forms the acu te or the he pa tic pha se. Af ter 4 months, the bi li ary or chro nic pha se be gins in which egg pro du cing starts and pa ra si tes or the ir eggs are se en in sto ol du ring this pe ri od. All of our ca ses we re in acu te or early bi li ary pha se. Most of the stu di es abo ut he pa to bi li ary fas ci o - li a sis in vol ved spo ra dic ca ses di ag no sed af ter the pa ti ents at ten ding the hos pi tal with so me symptoms. In this re port, only two ca ses had pre sen ted to our hos pi tal and the ot hers we re de tec ted af ter fa mily in ves ti ga ti on wit ho ut any se ri o us comp la - int. Anot her im por tant po int is that our study inc Turkiye Klinikleri J Med Sci 2009;29(5)

5 Radiology lu des 11 pe di at ric ca ses un der age 15, which is the most wi dest se ri es in the li te ra tu re to the best of our know led ge. In ves ti ga ti on of the pa ra si te or its eggs in sto - ol or du o de nal as pi ra te is the ma in di ag nos tic met - hod. Ho we ver, they are of ten dif fi cult to de tect in sto ol and pa ra si tes do not pro du ce ova in he pa tic sta ge. We de tec ted ova in sto ol only in 11 ca ses. This re sult al so sho wed that our ca ses co uld be in the acu te pha se. Eo si nop hi li a, high IgE le vels and li ver func ti on tests are the ot her la bo ra tory ab nor - ma li ti es. In our se ri es, eo si nop hi li a and high IgE le - vels we re the most sig ni fi cant tests. The re was no re la ti ons hip bet we en ra di o lo gi cal pat tern and la b- o ra tory fin dings and bet we en pe di at ric and adult pa ti ents. Se ro lo gi cal tests we re con si de red the ma - in di ag nos tic met hod and ELI SA was used to confirm the di ag no sis. Ra di o lo gi cal met hods that may be used for diag no sis are US, CT and MRI. The pri mary ra di o lo - gi cal met hod is US. Ho we ver, alt ho ugh it is non-in va si ve and inex pen si ve, US may not be diag nos tic in the he pa tic pha se be ca u se of the he te - ro ge ne ity of the li ver pa rench yma du e to the po orly de fi ned no du les. In our study, US de mons - tra ted li ver le si ons in 11 ca ses and the re was no signi fi cant li ver ab nor ma lity in 13 ca ses. Thus, it can not be con si de red a re li ab le mo da lity in the radi o lo gi cal di ag no sis of fas ci o li a sis es pe ci ally in the acu te pha se. Ho we ver, it is mo re use ful in the bi li - ary pha se of the di se a se, which re ve als ir re gu lar thic ke ning of the CBD wall and bi li ary di la ti on. 5-8 US may re ve al mi xed ec ho ge ni ti es with ir re gu lar bor ders. 1,2 Mo bi le, cur vi li ne ar, oval, and le af-li ke or cong lo me ra te hype rec ho ge nic ver mi form structu res wit ho ut aco us tic sha do wing wit hin the gallblad der and in the bi le ducts, which rep re sent worms might be spe ci fic in the di ag no sis of the di s- e a se. 3,4,7,8 So nog rap hi cally we ob ser ved sus pi ci o us ec ho ge nic ma te ri al in one ca se wit hin the lu men pro ving in tra lu mi nary pa ra si tes and it was ve ri fi ed with MRCP exa mi na ti on. CT is a much mo re use ful di ag nos tic mo da lity than US in the he pa tic pha se of the di se a se. It helps with the di ag no sis in 90% of the pa ti ents with acu - Avcu et al te fas ci o li a sis. Mul tip le, small, hypo dens le si ons with ir re gu lar bor ders, as well as branc hing fo ci of mic ro abs ces ses and sub cap su lar lo ca li za ti on of the tract li ne fas hi on le si ons are the cha rac te ris tic CT fin dings of the di se a se. 2 In cre a se in IgE and eo si - nop hil le vels with typi cal CT fin dings is sig ni fi cant for the di ag no sis. Most of the ca ses in our study we - re in the acu te pha se and CT sho wed va ri o us le si - ons in 20 out of 23 ca ses, which was su pe ri or to US. Pe ri por tal and hi lar lympha de no pathy was pro mi - nent in 7 ca ses, which was very in fre qu ently re por - ted in the li te ra tu re. 5 It is im por tant to ke ep in mind that hi lar lympha de no pathy and li ver le si ons may be mis di ag no sed as me tas ta ses such as the two pa ti ents pre sen ting to our cli nic with a pre sump ti - ve di ag no sis of he pa tic me tas ta sis cli ni cally. We al so de mons tra ted bi li ary di la ta ti on in 6 ca ses which was se en both in US and CT. He re in anot her im por tant fin ding is pe rip he ral en han ce - ment of di la ted bi li ary ducts which was se en in 4 ca ses with bi li ary di la ti on. Pe ric ho le doc hal en han - ce ment was ob vi o usly in the por tal pha se, which was con cor dant with ot her re ports in the li te ra tu - re. This ap pe a ran ce pro bably de pends on the me ta - bo li tes which ir ri ta te the mu co sa of the bi le duct, or duc tal hyperp la si a and hyper trop hi a of the duct epit he li um re sul ting in thic ke ning of the duct wall and pe ri duc tal fib ro sis. 9,10 MRI inc lu ding MRCP is anot her im por tant mo da lity for he pa to bi li ary fas ci o li a sis. MRI can de - mons tra te he pa tic le si ons cle arly in de ta il. Bi li ary ducts can be best eva lu a ted with MRCP. In 4 ca ses with bi li ary di la ta ti on, MRCP de pic ted bi li ary dila ta ti on in all and al so de mons tra ted in tra lu mi nal fil ling de fect in 2 of them. Di ag no sis may be de la yed be ca u se of the wi de spec trum of the dif fe ren ti al di ag no sis and low in ciden ce of the F. he pa ti ca in fec ti on. Si mi lar ab nor - mal US and CT fin dings may rep re sent vi ral he pa ti tis, li ver abs cess, ma lig nancy, cho lecy sti tis, scle ro sing cho lan gi tis and AIDS-re la ted cho lan gi - tis, rup tu red hyda tic cyst, and pa ra si tes such as as ca ri a sis and clo norc hi a sis F. he pa ti ca in fes ta - ti on was re por ted to re semb le he pa tic mass le si on on US and to be as so ci a ted with he pa tic eo si nop hi - Turkiye Klinikleri J Med Sci 2009;29(5) 1153

6 Avcu ve ark. lic gra nu lo ma. 15,16 With ade qu a te know led ge on the his tory, cli ni cak ma ni fes ta ti ons, la bo ra tory da ta and ra di o lo gi cal pat tern, the di ag no sis of the di se - a se is not dif fi cult. As a re sult, in he pa to bi li ary fas ci o li a sis, ra di o - lo gi cally sig ni fi cant signs may be se en even tho ugh cli ni cal fin dings do not ap pe ar. CT is mo re ef fec ti - Radyoloji ve than US es pe ci ally in acu te pha se and it can be di ag nos tic if eva lu a ted in cor re la ti on with la bo ra - tory fin dings. Pe rip he ral duc tal en han ce ment may be an im por tant sign of bi li ary in vol ve ment of the di se a se. MRCP is a use ful met hod in de mons tra ting bi li ary di la ta ti on and in tra lu mi nal fil ling de fects, which cor res pond to pa ra si tes. 1. Pul pe i ro JR, Ar mes to V, Va re la J, Cor re do i ra J. Fas ci o li a sis: fin dings in 15 pa ti ents. Br J Radi ol 1991;64(765): Han JK, Cho i BI, Cho JM, Chung KB, Han MC, Kim CW. Ra di o lo gi cal fin dings of hu man fas ci - o li a sis. Ab dom Ima ging 1993;18(3): Pri ce TA, Tu a zon CU, Si mon GL. Fas ci o li a sis: ca se re ports and re vi ew. Clin In fect Dis 1993;17(3): Sez gin O, Al tin taş E, Di şi be yaz S, Sa ri taş U, Sa hin B. He pa to bi li ary fas ci o li a sis: cli ni cal and ra di o lo gic fe a tu res and en dos co pic ma na ge - ment. J Clin Gas tro en te rol 2004;38(3): Ka ba a li oğ lu A, Cu buk M, Se nol U, Ce vi kol C, Ka ra a li K, Apay din A, et al. Fas ci o li a sis: US, CT, and MRI fin dings with new ob ser va ti ons. Ab dom Ima ging 2000;25(4): Pa go la Ser ra no MA, Ve ga A, Or te ga E, González A. Com pu ted to mog raphy of he pa - tic fas ci o li a sis. J Com put As sist To mogr 1987; 11(2): REFERENCES 7. Van Be ers B, Prin got J, Ge u bel A, Tri ga ux JP, Bi ga ig non G, Do oms G. He pa to bi li ary fas ci o - li a sis: no nin va si ve ima ging fin dings. Ra di o logy 1990;174(3 Pt 1): Fos ter JR. A study of the ini ti a ti on of bi li ary hyperp la si a in rats in fec ted with Fas ci o la he pa - ti ca. Pa ra si to logy 1981;83(Pt 2): Ak soy DY, Ke ri moğ lu U, Oto A, Er gü ven S, Ars lan S, Unal S, et al. Fas ci o la he pa ti ca in fec - ti on: cli ni cal and com pu te ri zed to mog rap hic fin dings of ten pa ti enpts. Turk J Gas tro en te rol 2006;17(1): Ce vi kol C, Ka ra a li K, Se nol U, Ka ba a li oğ lu A, Apay din A, Sa ba R, et al. Hu man fas ci o li a sis: MR ima ging fin dings of he pa tic le si ons. Eur Ra di ol 2003;13(1): Car roll BA, Op pen he i mer DA. Scle ro sing cho - lan gi tis: so nog rap hic de mons tra ti on of bi le duct wall thic ke ning. AJR Am J Ro ent ge nol 1982;139(5): Te e fey SA, Ba ron RL, Rohr mann CA, Shuman WP, Fre eny PC. Scle ro sing cho lan gi tis: CT fin dings. Ra di o logy 1988;169(3): Dol match BL, La ing FC, Fer der le MP, Jef frey RB, Cel lo J. AIDS-re la ted cho lan gi tis: ra di og - rap hic fin dings in ni ne pa ti ents. Ra di o logy 1987;163(2): Ooms HW, Puy la ert JB, Van der Werf SD. Bi l- i ary fas ci o li a sis: US and en dos co pic ret rog ra - de cho lan gi o pan cre a tog raphy fin dings. Eur Ra di ol 1995;5(2): De mir S, El li do kuz E, De ğir men ci B, Yü cel A, Gök çe Ç. [An asym pto ma tic fas ci o la he pa ti ca in fes ta ti on re semb ling a he pa tic mass le si on in ul tra so nog raphy: ca se re port]. Tur ki ye Kli nik - le ri J Med Sci 2005;25(1): Akı sü Ç, Me ral M, De li baş SB, Gün gör Ö, Ak soy Ü, Sa ğol Ö, et al. [Fas ci o li a sis; a ca se with eo - si nop hi lic gra nu lo ma in the li ver]. Tur ki ye Kli nik - le ri J Gas tro en te ro he pa tol 2004;15(2): Turkiye Klinikleri J Med Sci 2009;29(5)